A new path to mentorship for emerging global health leaders in low-income and middle-income countries
Authors: Meherunissa Hamid, Muneera A Rasheed
Journal: The Lancet Global Health (2022)

The fifth annual Global Health 50/50 report1Allotey P Reidpath DD Improving diversity in global health governing boards.Lancet. 2022; 399: 1673-1675Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar highlighted that 75% of the 2000 governing board seats are held by high-income countries (HICs), of which 51% are from two countries (USA and UK), while a mere 2·5% are held by people from low-income countries (LICs). Given this evidence, it is imperative to mentor early-career and mid-career global health professionals from low-income and middle-income countries (LMICs) as leaders to improve diversity of boards at the global level. Evidence strongly suggests that mentorship is inarguably crucial for nurturing future global health leaders. This can be particularly challenging when there are considerably fewer leaders from LMICs due to the existing inequities in global health leadership.1Allotey P Reidpath DD Improving diversity in global health governing boards.Lancet. 2022; 399: 1673-1675Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Current narratives on equitable partnerships mostly include academics and practitioners based in HICs who have focused on assuming responsibility for mentoring their LMIC partners.2Binagwaho A Allotey P Sangano E Ekström AM Martin K A call to action to reform academic global health partnerships.BMJ. 2021; 375n2658PubMed Google Scholar We believe this approach has several challenges including lack of incentivisation for the HIC collaborator, due to the time and resources spent mentoring their own students and staff.3Hedt-Gauthier B Airhihenbuwa CO Bawah AA et al.Academic promotion policies and equity in global health collaborations.Lancet. 2018; 392: 1607-1609Summary Full Text Full Text PDF PubMed Scopus (34) Google Scholar Additionally, mentorship outcomes aligned with their institutional and national priorities might not align with those in LMICs. To truly shift power, LMIC collaborators must take ownership and identify context specific and nuanced skill sets needed for mentors and mentees. This is one of the few sustainable approaches to end dependency on HICs for training of our global health professionals and scientists. In this Comment, we, women from and based in Pakistan, use our experiences from two different settings to argue and challenge the assumption that the dearth of leaders in LMICs is a symptom of lack of willingness in LMIC institutions rather than their lack of capacity (defined as provision of time, resources including networking opportunities, and a willingness to invest in mentees, professionally and emotionally) to mentor young investigators. Notably, we found very little discussion on mentorship to develop future leaders by LMIC global health leaders. There is evidence, albeit mostly from HICs, of existing toolkits for mentorship for LMICs that could be adapted to local institutional settings or even used to create new context-specific plans for mentorships.4Hansoti B Kalbarczyk A Hosseinipour MC et al.Global health mentoring toolkits: a scoping review relevant for low-and middle-income country institutions.Am J Trop Med Hyg. 2019; 100: 48-53Crossref PubMed Scopus (9) Google Scholar We found that none of the available mentorship toolkits identified human centeredness as a key competency, that is, valuing empathy and relationship building between the mentor and the mentee built on equitable sharing of power and shedding of privilege within hierarchical structures. The HIC authors of these toolkits have not considered the deeply embedded hierarchical culture prevalent in many LMICs, which is a crucial challenge to relationship building and inculcating empathy for effective mentorship practices.5Schwerdtle P Morphet J Hall H A scoping review of mentorship of health personnel to improve the quality of health care in low and middle-income countries.Global Health. 2017; 13: 77Crossref PubMed Scopus (41) Google Scholar This could be because considering cultural change within institutions in LMIC settings will delay the short-term benefits of implementing formal training programmes. Therefore, we believe mentorship interventions have to be driven by professionals in LMICs. The major challenge to shift the local power imbalance is that power structures within global health have (un)intentionally produced leaders in LMICs with a similar colonial mindset to that seen in HICs, which reinforces power being concentrated in few hands, including mentorship of future leaders. For example, current leaders who attract the most funding gain control over international grants that results in substantial power over their institutions. This is compounded by complex systems that have created barriers such as hierarchy, bureaucracy, and capacity, limiting mentorship opportunities. An example of this is the use of bullying, which is frequently used in academia as a career tool.6Täuber S Mahmoudi M How bullying becomes a career tool.Nat Hum Behav. 2022; 6: 475Crossref PubMed Scopus (9) Google Scholar When power is scarce for global health leaders in LMICs, the probability of bullying becomes greater and only the fittest can survive.6Täuber S Mahmoudi M How bullying becomes a career tool.Nat Hum Behav. 2022; 6: 475Crossref PubMed Scopus (9) Google Scholar Based on our experiences, we observed two types of mentorship practices in LMICs (appendix p 2) ranging from virtually none or limited mentorship to overdoing, which we believe have not achieved the required outcomes. The two types of mentorship are: ad hoc mentorship that provides limited opportunity for intellectual and professional development; and mentorship that rewards and thus encourages limited intellectual efforts from the mentees. Given these ineffective practices, it is imperative to describe what effective mentorship looks like. One example of the effectiveness of mentorship could be the impact a mentee has in the global health sphere, locally and, eventually, globally. A large-scale study of thousands of scientists around the world found that "mentees achieved the highest impact when they displayed intellectual independence from their mentors and did their best work when they break from their mentors' research topics".7Ma Y Mukherjee S Uzzi B Mentorship and protégé success in STEM fields.Proc Natl Acad Sci USA. 2020; 117: 14077-14083Crossref PubMed Scopus (22) Google Scholar For mentees in LMICs to achieve such an impact, the process will have to entail allowing them to follow an independent track with structured pathways in place. Mentorship hence becomes a pivotal part of the larger succession planning in global health. Moving forward, different actors of global health, from LMICs and HICs, will have to play their part to create willingness for mentorship interventions as outlined in the panel. We conclude that there is a dire need to mentor investigators in LMICs to reduce inequities in global health leadership. If left as is, we will continue to perpetuate the same cycle of inequities, where privileged mentees become global health leaders driving the development of a cadre of professionals who are stuck in the same role, and unable to advance their career to contribute to the field meaningfully.PanelRecommendations to strengthen mentorship for emerging leaders in LMICsGlobal health institutions in LMICs •Incentivisation is key to behaviour change. Explicitly include mentoring as part of the professional agenda and development of mentors, as well as for their self-interest and personal growth.•Institutional promotion criteria, annual appraisal, and strategic planning meetings should include evaluation for the quality of mentorship. Examples of successful mentee outputs and a gradual increase in quality or complexity of these outputs should be seen as success stories to be celebrated.•Grants and manuscripts co-authored, although valuable, should be considered as opportunities on the journey to be trained as independent investigators.8Busse CE Anderson EW Endale T et al.Strengthening research capacity: a systematic review of manuscript writing and publishing interventions for researchers in low-income and middle-income countries.BMJ Glob Health. 2022; 7e008059Crossref PubMed Scopus (1) Google Scholar•When structural changes are implemented to dismantle the current system, there will be resistance by those who hold power. Therefore, to reduce such anticipated resistance, it is important to simultaneously build an institutional culture where mentorship is valued, especially the culture of celebrating the success of mentees as independent scientists.•A cultural transformation can also help avoid instances of tokenism. The value of human centeredness should underpin the new culture that is a prerequisite to effective mentorship.Global health mentees •Mentees should pick their advisors wisely if they want to be trusted as leaders in their respective fields. Although it is understandable that working with advisors in power has substantial benefits for one's career, the time and commitment required to nurture an individual might not always be available to them.•From the mentees' perspective, the path of picking advisors wisely might not just be harder, but also longer; however, there are no short-cuts to impact (even if there are to academic success).Global health institutions in HICs •Include clear roles and responsibilities of mentorship as part of the terms of references in contract agreements. However, it needs to be clear that in an equitable partnership, both parties have something to gain too. Hence, the HIC partners should also assume a mentee role.•Development of the research staff should be seen as a shared responsibility between the HIC and LMIC institutions.•Principal investigators in LMICs can similarly mentor mentees from HICs for different skill sets (eg, community engagement and project management in low-resource settings). These learning opportunities provided by project sites to HIC collaborators can be used to negotiate mentorship opportunities for their investigators.Funders •For an institution to be considered a potential grantee by a funder, the evaluation criteria should include beyond an overall figure of number of projects executed or grant money till date.•There should be examples of demonstrated professional development of investigators over time, including an increase in diversity of investigators and research areas, number of doctoral candidates enrolled or completed, and their academic achievements.•An institution dependent on one or two individuals for their funding over a long period of time needs to be questioned and should raise concerns for development of the younger generation.Journals •Journals should request a reflexivity statement for studies in LMICs to acknowledge the role of an early career researcher or practitioner collaborating with an established researcher.•It can be similar to the recent consensus statement recommending inclusion of a reflexivity statement in manuscripts in collaboration between LMICs and HICs.9Morton B Vercueil A Masekela R et al.Consensus statement on measures to promote equitable authorship in the publication of research from international partnerships.Anaesthesia. 2022; 77: 264-276Crossref PubMed Scopus (22) Google Scholar•We understand this needs to be done carefully given the vulnerability of the young investigator in the institution but believe it can also encourage important conversations, facilitating the creation of a new culture.NBCs •The ethical framework and the scope of committees can be expanded to include staff and investigators specifically working on international projects.10Köhler J Reis AA Saxena A A survey of national ethics and bioethics committees.Bull World Health Organ. 2021; 99: 138-147Crossref PubMed Scopus (2) Google Scholar•The NBCs should request the institutions for strategic plans to accompany the ethics review applications. These plans should cover, for example, the kind of local capacity being strengthened such as enrolment of new doctoral students, number of completed doctorates, number of new investigators, and new thematic areas being planned or developed, along with how ideas will be scaled and lead to a decrease in inequity and disparity, and help improve the lives of the marginalised communities.•International grants must be an opportunity for capacity strengthening of our investigators, which should be considered as their fundamental right. It is time for LMIC scientists and implementers to be more than just "glorified data collectors".11Odjidja EN What is wrong with global health? So-called glorified data collectors in low-income regions.Lancet Glob Health. 2021; 9e1365Summary Full Text Full Text PDF PubMed Scopus (3) Google ScholarHIC=high-income country. LMIC=low-income and middle-income country. NBCs=national bioethics committees Global health institutions in LMICs •Incentivisation is key to behaviour change. Explicitly include mentoring as part of the professional agenda and development of mentors, as well as for their self-interest and personal growth.•Institutional promotion criteria, annual appraisal, and strategic planning meetings should include evaluation for the quality of mentorship. Examples of successful mentee outputs and a gradual increase in quality or complexity of these outputs should be seen as success stories to be celebrated.•Grants and manuscripts co-authored, although valuable, should be considered as opportunities on the journey to be trained as independent investigators.8Busse CE Anderson EW Endale T et al.Strengthening research capacity: a systematic review of manuscript writing and publishing interventions for researchers in low-income and middle-income countries.BMJ Glob Health. 2022; 7e008059Crossref PubMed Scopus (1) Google Scholar•When structural changes are implemented to dismantle the current system, there will be resistance by those who hold power. Therefore, to reduce such anticipated resistance, it is important to simultaneously build an institutional culture where mentorship is valued, especially the culture of celebrating the success of mentees as independent scientists.•A cultural transformation can also help avoid instances of tokenism. The value of human centeredness should underpin the new culture that is a prerequisite to effective mentorship. Global health mentees •Mentees should pick their advisors wisely if they want to be trusted as leaders in their respective fields. Although it is understandable that working with advisors in power has substantial benefits for one's career, the time and commitment required to nurture an individual might not always be available to them.•From the mentees' perspective, the path of picking advisors wisely might not just be harder, but also longer; however, there are no short-cuts to impact (even if there are to academic success). Global health institutions in HICs •Include clear roles and responsibilities of mentorship as part of the terms of references in contract agreements. However, it needs to be clear that in an equitable partnership, both parties have something to gain too. Hence, the HIC partners should also assume a mentee role.•Development of the research staff should be seen as a shared responsibility between the HIC and LMIC institutions.•Principal investigators in LMICs can similarly mentor mentees from HICs for different skill sets (eg, community engagement and project management in low-resource settings). These learning opportunities provided by project sites to HIC collaborators can be used to negotiate mentorship opportunities for their investigators. Funders •For an institution to be considered a potential grantee by a funder, the evaluation criteria should include beyond an overall figure of number of projects executed or grant money till date.•There should be examples of demonstrated professional development of investigators over time, including an increase in diversity of investigators and research areas, number of doctoral candidates enrolled or completed, and their academic achievements.•An institution dependent on one or two individuals for their funding over a long period of time needs to be questioned and should raise concerns for development of the younger generation. Journals •Journals should request a reflexivity statement for studies in LMICs to acknowledge the role of an early career researcher or practitioner collaborating with an established researcher.•It can be similar to the recent consensus statement recommending inclusion of a reflexivity statement in manuscripts in collaboration between LMICs and HICs.9Morton B Vercueil A Masekela R et al.Consensus statement on measures to promote equitable authorship in the publication of research from international partnerships.Anaesthesia. 2022; 77: 264-276Crossref PubMed Scopus (22) Google Scholar•We understand this needs to be done carefully given the vulnerability of the young investigator in the institution but believe it can also encourage important conversations, facilitating the creation of a new culture. NBCs •The ethical framework and the scope of committees can be expanded to include staff and investigators specifically working on international projects.10Köhler J Reis AA Saxena A A survey of national ethics and bioethics committees.Bull World Health Organ. 2021; 99: 138-147Crossref PubMed Scopus (2) Google Scholar•The NBCs should request the institutions for strategic plans to accompany the ethics review applications. These plans should cover, for example, the kind of local capacity being strengthened such as enrolment of new doctoral students, number of completed doctorates, number of new investigators, and new thematic areas being planned or developed, along with how ideas will be scaled and lead to a decrease in inequity and disparity, and help improve the lives of the marginalised communities.•International grants must be an opportunity for capacity strengthening of our investigators, which should be considered as their fundamental right. It is time for LMIC scientists and implementers to be more than just "glorified data collectors".11Odjidja EN What is wrong with global health? So-called glorified data collectors in low-income regions.Lancet Glob Health. 2021; 9e1365Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar HIC=high-income country. LMIC=low-income and middle-income country. NBCs=national bioethics committees We declare no competing interests. Download .pdf (.14 MB) Help with pdf files Supplementary appendix